Provider Demographics
NPI:1902412562
Name:GILLESPIE, LINDSAY
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4036 TRINITY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7714
Mailing Address - Country:US
Mailing Address - Phone:408-398-3464
Mailing Address - Fax:
Practice Address - Street 1:7400 RANCHO LOS GUILICOS RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-6540
Practice Address - Country:US
Practice Address - Phone:707-565-8175
Practice Address - Fax:707-565-8190
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA351842251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA35184OtherPT BOARD OF CALIFORNA